Provider Demographics
NPI:1164592010
Name:GREEN, CRYSTAL ELAINA (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:ELAINA
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33663
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3663
Mailing Address - Country:US
Mailing Address - Phone:619-318-6573
Mailing Address - Fax:
Practice Address - Street 1:1807 ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-7633
Practice Address - Country:US
Practice Address - Phone:619-318-6573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT38882106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist